Sleep Disturbances and Emotional and Behavioral Difficulties Among Preschool-Aged Children

Key Points Question Is a natural history of sleep disturbances associated with resolved and incident emotional and behavioral difficulties (EBDs) during preschool years? Findings In this cohort study of 17 182 preschool-aged children in Shanghai, China, incident and stable sleep disturbances were negatively associated with resolved EBDs but positively associated with incident EBDs after adjustment. Resolved sleep disturbances were positively associated with resolved EBDs. Meaning These findings underscore the association between sleep disturbances and EBDs among preschool-aged children and the importance of sleep health in promoting their mental well-being.


Sleep Disturbances
The reliability and validity of the Mandarin version of the Children's Sleep Habits Questionnaire (CSHQ) have been demonstrated in several studies. 1,2Parents rate the frequency for each item on a 3point Likert Scale based on observations of their children during the past recent week or a typical week: "usually" (5-7 times per week), "sometimes" (2-4 times per week), and "rarely" (0-1 time per week).A higher total score on the CSHQ indicates greater sleep disturbances.In this study, the CSHQ yielded an acceptable Cronbach's alpha coefficient of 0.74 at the year of entry, 0.77 at the year of graduation.Furthermore, the progression of specific sleep disturbances (8 types of sleep disturbances ) was categorized into 4 groups: individuals with no sleep disturbances at both time points, individuals with resolved sleep disturbances (RSDs) who had sleep disturbances in the year of entry but not in the year of graduation, individuals with incident sleep disturbances (ISDs) who had sleep disturbances in the year of graduation but not in the year of entry, individuals with stable sleep disturbances (SSDs) who had sleep disturbances at both time points.

Emotional and Behavioral Disturbances (EBDs)
Using the Strengths and Difficulties Questionnaire, parents rate the children's behavior in the past six months on a 3-point Likert scale: not true=0, somewhat true=1, and definitely true=2.The total difficulties score is calculated by summing the scores of the 4 difficulties subscale scores.In this study, the Cronbach's alpha coefficient for the full scale was 0.80 at year of entry and 0.83 at graduation year.

Confounding factors
We examined several variables as potential confounders, such as child characteristics, socioemotional status (including maternal educational level, and family annual income), maternal psychological status and caring environment.Initially, we calculated the duration of a child's nightly sleep (NSD) on workdays (NSD-workday) and on free days (NSD-freeday) as the number of hours between bedtime and wake time.NSD.Nighttime sleep duration was categorized into two group (less than 9 hours and 9 hours or more). 3Children's weight status was assessed using the z-scores of their Body Mass Index (BMI). 4Daily screen time exceeding 1 hours per day was considered as excessive. 5Demographic information such as the parents' marital status (divorced or not), the child's gender, age at school entry, primary caregiver (parent or other), and number of siblings was collected.The Index of Child Caring Environment (ICCE) was utilized to assess the quality of caring environment and categorized into 5 rankings (raw scores ≤1, 1.01-2, 2.01-3, 3.01-4, 4.01-5), with higher rankings indicated better quality. 6reover, we evaluated parent-child interactions using the China Parent-Child Interaction Scores (CPCIS), 7 a questionnaire that gauges the quantity of the most prevalent activities related to learning, reading, recreation, and environment interaction.Total scores were divided into 5 ranks (raw scores ≤9, =10, =11, =12, =13) based on the frequency of parent-child interactive activities, with higher scores indicating more interaction.All these confounders were evaluated at the year of entry except for maternal psychological status, which was examined using the World Health Organization's five-item well-being index (WHO-5) and separated into abnormal (total scores<13) and normal (total scores ≤13) groups at the year of graduation.

Multiple imputation
To address potential bias due to attrition and to handle missing values, multiple imputation with chained equations 9 was used for the sample that had complete data on the SDQ at graduation year of preschool (17 182).For the current analyses, 50 imputed datasets were created using information from the included variables with information from 4 additional variables associated with observed data and missingness, i.e., birth weight status, breastfeeding, kindergartens, and districts.

Sensitive analysis
First, the cut-off of 41 for the CSHQ total score was used to act as a broad definition of sleep disturbances (eTable 3 in Supplement 3).To examine the association between sleep disturbances and more severe EBDs, we used a narrower definition of abnormal in EBDs (eTable 4 in Supplement 3).In addition, we conducted the regression in the datasets in which mothers have a normal emotional status, taking into account the possible reporting bias for children's sleep disturbances and EBDs (eTable 5 in

eMethods 1 .
Choice of Primary Measures eFigure 1. Directed Acyclic Graph eMethods 2. Statistical Analysis eFigure 2. Flow Diagram of Included Participants eTable 1. Summary Statistics of Main Variables in the Observed Complete-Case Data Set (n = 16 000) and the Imputed Data Set (n = 17 182) eTable 2. Prevalence of Each Sleep Disturbance eTable 3. Association Between Sleep Status Transition From Preschool Year of Entry to Year of Graduation and Transition of EBDs eTable 4. Association Between Sleep Status Transition From Preschool Year of Entry to Year of Graduation and Transition of EBDs (Narrow Definition) eTable 5. Association Between Sleep Status Transition From Preschool Year of Entry to Year of Graduation and Transition of EBDs in Data Sets in Which Mothers Had Normal Emotional Status eFigure 3. The Odds Ratio of Resolved Emotional and Behavioral Difficulties (EBDs) for Children With the Transition of Various Sleep Disturbances Compared With Children With Stable Sleep Disturbances eReferences This supplementary material has been provided by the authors to give readers additional information about their work.© 2023 Deng Y et al.JAMA Network Open.

eFigure 2 .
Flow Diagram of Included Participants 20 324 Total sample of SCHEDULE-P Cohort at preschool year of entry 17 233 Total sample of SCHEDULE-P Cohort at preschool year of graduation 17 182 Response to SDQ at both entry and year of graduation 16 000 Response to data on relevant variables used in the regression Lost to follow up (N=3 091) a) 6 kindergartens closed (N=330) b) 2 children died (N=2) c) Lost contact (N=2 651) d) Refused to participate the survey (N=108) 17 182 Imputed dataset (analytic sample) Imputed based on responses to birth weight status, breastfeeding, schools, and districts.Missing information on relevant variables (N=1 182) Missing data on SDQ at year of entry (N=28) Missing data on SDQ at year of graduation (N=24) © 2023 Deng Y et al.JAMA Network Open.

value Resolved EBDs in children with EBDs at preschool year of entry
Association Between Sleep Status Transition From Preschool Year of Entry to Year of Graduation and Transition of EBDs scores, nighttime sleep duration, screen exposure time, weight status measured at preschool year of entry, and maternal emotional status measured at preschool year of graduation.Sleep disturbances, Children's Sleep Habits Questionnaire total scores >41.Association Between Sleep Status Transition From Preschool Year of Entry to Year of Graduation and Transition of EBDs (Narrow Definition) Association Between Sleep Status Transition From Preschool Year of Entry to Year of Graduation and Transition of EBDs in Data Sets in Which Mothers Had Normal Emotional Status adjusted for sex, age, maternal educational level, family annual income, siblings, Chinese Parent-Child Interaction Scale total scores, nighttime sleep duration, screen exposure time, weight status measured at preschool year of entry, and maternal emotional status measured at preschool year of graduation.Sleep disturbances, Children's Sleep Habits Questionnaire total scores >48; Odds of Resolved Emotional and Behavioral Difficulties for Children With Transition of Different Sleep Disturbances Comparisons are with children with stable sleep disturbances.All the P values are presented after Bonferroni multiple testing adjustments.AOR indicates adjusted odds ratio; CSHQ, Children's Sleep Habits Questionnaire.
© 2023 Deng Y et al.JAMA Network Open.eTable 3. Abbreviation: EBDs, emotional and behavioral difficulties; NA, not applicable; OR, odds ratio.aadjustedforsex, age, maternal educational level, family annual income, siblings, Chinese Parent-Child Interaction Scale total © 2023 Deng Y et al.JAMA Network Open.eTable 4. Abbreviation: EBDs, emotional and behavioral difficulties; NA, not applicable; OR, odds ratio.aadjustedfor sex, age, maternal educational level, family annual income, siblings, Chinese Parent-Child Interaction Scale total scores, nighttime sleep duration, screen exposure time, weight status measured at preschool year of entry, and maternal emotional status measured at preschool year of graduation.Sleep disturbances, Children's Sleep Habits Questionnaire total scores >48; © 2023 Deng Y et al.JAMA Network Open.eTable 5. Abbreviation: EBDs, emotional and behavioral difficulties; NA, not applicable; OR, odds ratio.a© 2023 Deng Y et al.JAMA Network Open.eFigure 3.